Care Coordinator

• Work collaboratively with a multidisciplinary care team across the continuum of care for high-risk patients
• Provide care and disease management coordination
• Identify patients in the specialty care practice that have ongoing coordination needs and conduct targeted outreach
• Conduct comprehensive clinical assessments that include disease/age-specific, medical, behavioral, pharmacy, social, and end of life needs of each patient
• Inform and work with patients and their families regarding coordination of their care, provide education and coaching, monitor patient compliance with their care plan, perform reassessments regarding patient progress toward goals, and update plan of care
• Serve as a liaison and advocate for patients and families
• Assist in managing transitions of care across care settings, ensuring optimal communication and planning
• Identify barriers, facilitate solutions, and connect others to community resources

RN Care Coordinator at Cleveland Clinic focusing on high-risk patient care

RN Care Coordinator – Epilepsy

RN Care Coordinator at Cleveland Clinic coordinating care for high-risk patients through collaborative approaches. Engaging with multidisciplinary teams to improve patient outcomes while promoting wellness.

• support Long Term Care (LTC) Care Coordination through activities such as member outreach and mailings, appointment scheduling and reminders, prescription coordination, and provider follow-up
• Works with senior care management team to support care management activities and the teams assigned to members
• Serves as a liaison alongside care managers and providers to ensure proper coordination of care for members
• Provides outreach to members via phone or home visits to engage members and discuss care plan/service plan
• Coordinates care activities based on the care plan/service plan and works with healthcare and community providers and partners
• Develops in-depth knowledge of care management services including responding to some complex or escalated issues
• Documents and maintains member records in accordance with state and regulatory requirements

Care Coordinator supporting LTC Care Coordination in member outreach and service.

Care Coordinator III

Care Coordinator supporting Long Term Care Care Coordination through activities like member outreach and appointment scheduling. Collaborating with healthcare and community providers to ensure continuity of care.

• Work within The James and collaborate with affiliate members of the James Cancer Network program for patients with a cancer diagnosis.
• Serve as a point of contact for cancer patients who are referred or come as a self-referral from James Cancer Network affiliate sites.
• Collaborate with multidisciplinary providers and professional staff within and across The James.
• Facilitate on-going communication between patients and both internal and external providers.
• Provide support and education to patients and their caregivers related to issues that may occur when facing a cancer diagnosis.

Care Coordinator for cancer patients at Ohio State’s James Cancer Network

Care Coordinator working with cancer patients at James Cancer Network, facilitating communication and education between patients and providers. Collaborating with multidisciplinary teams at Ohio State’s Wexner Medical Center.

• Assist in the immediate care coordination needs of youth hospitalized due to a behavioral health condition enrolled in the OhioRISE program.
• Support families with the hospital discharge process, educating families and community partners about the OhioRISE program, and making referrals for follow-up care and services.
• Attend in-person and virtual meetings to complete engagement milestones for the program, including crisis safety plans, assessments, care plans, and scheduling and facilitating Child and Family team meetings until a warm handoff can be made to the youths ongoing care coordinator.
• Join with family to identify care coordination needs/services in line with service delivery standards and program outcomes to ensure best outcomes for children, youth, and families.
• Work with families to define cultural factors that influence strengths, functioning, and family interaction styles to ensure ongoing engagement and success in care planning.
• Identify strengths of children, youth, and families for utilization in care coordination engagement and supporting healthy outcomes.
• Coordinate family-based-services for children, youth, and families in their home, school, and community.
• Ensure with family that services identified on care plans are the most appropriate, least restrictive, and meet the safety and treatment needs of the child, youth and family.
• Engage and build positive relationships with children, youth, and families in coordination with child and family teams to support successful integration of team members and care plans.
• Develop collaborative and creative partnerships with community resources to meet the diverse needs of youth and families.
• Maintain necessary documentation, participate in program evaluation, attend team and program planning meetings, cross-systems training, and acquire knowledge of community resources.
• Remain current with all training requirements including but not limited to High Fidelity Wraparound, MI, Cultural Humility, etc.

Engagement Care Coordinator assisting youth hospitalized due to behavioral health conditions.

Engagement Care Coordinator

Engagement Care Coordinator at Integrated Services for Behavioral Health supporting families of youths in behavioral health crisis. Assists with care coordination and resources for hospital discharge and follow-up care.

• Collaborates with clinic team members to provide evidence-based patient-centered care
• Helps patients stay up to date on care plans and related health goals
• Focuses on high-risk medically complex patients
• Acts as a liaison with patient’s family members and other agencies
• Facilitates improved communication for comprehensive whole person care
• Stays up to date on standards, assisting with programs and processes

Clinical Nurse Care Coordinator providing patient-centered care in Columbus

Registered Nurse, Care Coordinator – General Internal Medicine and Pediatrics

Clinical Nurse Care Coordinator at Ohio State University Physicians providing patient-centered care. Collaborating with clinic teams to support high-risk patients and improve health outcomes.

• Collaborates with clinic team members to provide evidence-based patient-centered care
• Helps patients stay up to date on care plans and related goals
• Focuses on high-risk medically complex patients, including those in care transitions
• Acts as a liaison with patients’ family members and other agencies
• Facilitates improved communication to provide comprehensive whole-person care
• Assists with programs and processes, staying up to date on standards

Clinical Nurse Care Coordinator at Ohio State University Physicians

Registered Nurse, Care Coordinator – Post Covid Care

Clinical Nurse Care Coordinator at Ohio State University Physicians providing evidence-based patient-centered care. Focusing on high-risk patients and facilitating communication for comprehensive whole-person care.

• Effectively engages children/youth with significant behavioral health needs and their family/caregivers for assigned caseload (1:10 for ICC and 1:25 for MCC)
• Builds and maintains knowledge of available community resources and helps to link youth and family to needed supports
• Conducts comprehensive CANS assessment and facilities development of an individualized, strength based Child and Family-Centered Care Plan
• Actively monitors plan to ensure services are provided in accordance with plan and helps to address challenges and barriers and updates/modifies plan as needed
• Facilitates Child and Family Team meetings and ensure the child and family have a voice and choices in their plan and providers
• Encourages creative solutions and use of natural supports with a goal of maintaining the youth in the community and in the least restrictive environment
• Develops safety-crisis plan with youth and family and reviews
• Ensures that initial and ongoing engagement, contacts and documentation are completed as required per CME rules.
• Must be willing to work flexible hours which may include evenings and/or weekends.
• Required to provide services in the home and other community setting.

Care Coordinator responsible for youth with complex needs

Care Coordinator position responsible for comprehensive care coordination activities for youth and families. Working remotely and engaging with the local community resources.

Care Coordinator jobs in Ohio

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RN Care Coordinator – Epilepsy

Care Coordinator III

Care Coordinator

Engagement Care Coordinator

Registered Nurse, Care Coordinator – General Internal Medicine and Pediatrics

Registered Nurse, Care Coordinator – Post Covid Care

Care Coordinator